Heart attack

Heart attacks are caused by atherosclerosis, which occurs in arteries around the body and is called cardiovascular disease. In heart disease, this is called coronary heart disease and is caused by the build-up of atheroma in the coronary arteries. This narrows the artery and causes a restricted blood flow. This process, known as atherosclerosis, can lead to angina and heart attacks

A heart attack (also known as myocardial infarction or MI) happens when the blood supply to your heart becomes completely blocked, either by the formation of a blood clot or by a loose piece of atheroma. This can result in damage to the part of your heart muscle, which that particular coronary artery was supplying.

Sometimes, when chest pain occurs suddenly, it is unclear if it is due to unstable angina or a heart attack. Until tests confirm the diagnosis, doctors sometimes call this Acute Coronary Syndrome (ACS).

Facts about heart attacks

• Most people survive heart attacks and make a good recovery.
• Your heart is one of the toughest muscles in your body – it's already healing itself.
• Your heart hasn’t worn out – a heart attack is usually caused by a blockage in one small section of an artery.
• Stress, shocks or surprises do not cause a heart attack.
• It is normal to feel tired, weak and emotional after a heart attack – this will pass.
• Many of the causes of heart attacks are under your control – it is never too late to reduce your risk of another heart attack.

A heart attack is an emergency situation and requires immediate medical help. Assessment of your situation will begin as soon as medical help arrives and will include:

• assessing how you look 
• finding out, if possible, about any heart conditions you already have
• asking anyone who is with you what happened
• performing initial tests which will help to find out what is happening to you
• providing treatment to minimise the amount of heart damage, relieve pain and prevent shock worsening

The symptoms of a heart attack

These include:

• chest pain - the pain is usually located in the centre of your chest and can feel like a sensation of pressure, tightness or squeezing
• pain in other parts of the body - it can feel as if the pain is travelling from your chest to your arms (usually the left arm is affected but it can affect both arms), jaw, neck, back and abdomen
• shortness of breath
• nausea
• an overwhelming sense of anxiety (similar to having a panic attack)
• feeling light headed
• coughing
• vomiting
• wheezing

Dial 999 immediately if you suspect that you or someone you know is having a heart attack.

Paramedics would much rather be called out to find out that an honest mistake has been made than be called out when it is too late to save a person’s life.

Waiting for the ambulance

• You should then sit and rest while you wait for the ambulance to arrive.
• If you are not allergic to aspirin and have some next to you, or if there is someone with you who can fetch them for you, chew one adult aspirin tablet (300mg). However, if they are not nearby, the person should stay with you - they should not go hunting for aspirin.
• Do not get up and look around for an aspirin. This may put unnecessary strain on your heart.

Like all of the other tissues and organs in the body, the heart needs a constant supply of oxygen-rich blood to survive. If the blood supply to the heart is suddenly interrupted, the heart muscles may be damaged

Left untreated, the heart muscle will experience irreversible damage. Risk factors for heart attack relate to coronary heart disease (CHD) and its development.

Risk factors

There are certain things that increase your risk of developing coronary heart disease. These are called risk factors and include:

High blood pressure

If your blood pressure is consistently higher than it should be, it is called high blood pressure (or hypertension).

High blood pressure is not a disease in itself. However, it can lead to an increased risk of heart disease and strokes. Over the years, high blood pressure slowly damages the blood vessels by making them narrower and more rigid. This means that your heart has to work harder to push the blood through your blood vessels, and the overall blood pressure rises, making it easier for clots to get caught and for fatty debris (atheroma) to block your blood vessels. This is what happens in heart attacks and strokes.

High cholesterol level

When the cholesterol level in your blood is high, it contributes to the fatty build-up in the lining of your blood vessels, called atheroma, which increases your risk of heart disease and strokes.

Most doctors use risk assessment charts to help identify your risk in terms of how likely you are to develop heart or stroke problems in the future. Based on your other risk factors, your doctor will decide what cholesterol level is safe for you.

Diabetes

Diabetes is one of the major risk factors for heart disease and stroke.

People who have diabetes are between 2 and 5 times more likely to develop heart disease and stroke than people who do not.

Uncontrolled diabetes contributes to damage to the blood vessels and the build-up of fatty deposits in the arteries, which increases the risk of heart disease and stroke.

People who have Type 2 diabetes are more likely to have high LDL ('bad') cholesterol, which is a risk factor for heart disease and stroke.

People who have Type 2 diabetes are also more likely to have high blood pressure – another risk factor for heart disease and stroke.

If you already have other cardiovascular risk factors, your risks multiply. The good news is that there are things you can do to control your diabetes and reduce your cardiovascular risks.

Smoking

The toxins that are contained in cigarettes both narrow the carotid arteries and damage them, which makes people who smoke more vulnerable to coronary heart disease. When you smoke, about 4,000 chemicals are released. These include at least 80 cancer-causing chemicals, hundreds of poisons and nicotine (a highly addictive drug). If you have a heart condition, smoking may make your symptoms worse.

Smoking makes the smooth lining of blood vessels rough. This encourages the build up of atheroma, the fatty material that narrows and blocks blood vessels.

Smoking increases the amount of fibrinogen (blood thickening agent) in the blood and makes it stickier. This increases the chance of blood clots forming that can cause heart attacks and strokes.

Smoking also increases blood pressure, speeds up the heart and increases the likelihood of heart disease, strokes and many cancers. It also damages the lungs, causing chronic lung disease.

The good news is that from the moment you stop smoking, the risks to your health start to decline.

Learn some effective ways to stop smoking

Not getting enough exercise

Getting more exercise can:

• increase your exercise tolerance which enables you to do more as you become fitter
• help lower cholesterol levels
• help lower high blood pressure
• help you lose weight
• keep you supple and more mobile
• strengthen your muscles, joints and bones
• reduce tension, encourage relaxation and promote sleep
• give you a sense of wellbeing and confidence
• help reduce anxiety and depression

Remember that the heart is a muscle and it needs to be exercised to keep it strong. When you are sitting still, it hardly has to work at all. The less you do, the less you are able to do.

Find out more about keeping active

Being overweight

Being overweight increases the work the heart has to do, contributes to high blood pressure, and may lead to abnormal levels of fat in the blood. It is also associated with diabetes, respiratory disease, gall bladder problems and some cancers.

Being able to control your weight and keep it within healthy levels can reduce your risk of cardiovascular disease and prevent chronic disease from worsening. It is a good idea to be as close as you can to your ideal weight. This is best achieved by controlling your weight through a balance of eating healthily and keeping as active as you can.

Your body mass Index (BMI) and your waist measurement are both accurate ways of assessing if your weight is within the normal range.

Find out how to measure your BMI

Drinking too much alcohol

It is important to moderate your alcohol intake as drinking heavily increases your blood pressure, affects your cholesterol level and can make you gain weight.

Binge drinking, that is drinking large amounts over a short period of time, is particularly harmful.

In the UK, a unit of alcohol is equivalent to 8g or 10mls of pure alcohol. The strength of alcohol is measured by the percentage of alcohol by volume (%ABV).

For example:

• There is 1 unit of alcohol in a single measure (25mls) of spirit of 37.5% vol.
• There are 1.5 units of alcohol in one small glass (125mls) wine or champagne of 12% vol.
• There is 1 unit of alcohol in half a pint of standard strength (3.5% vol) beer or lager.

Some people still think that 1 drink = 1 unit. This is not true! Remember, it is the strength and size of a drink that determines how many units it contains. You have to read the label to be accurate. Home measures are often more generous than those in a pub or restaurant. For example, a large 440ml bottle or can of strong beer (6.5%) has 3 units of alcohol in it.

Find out how to drink alcohol reponsibly

Unhealthy diet

There are some key changes you can make to your eating patterns which have been proven to be of benefit in reducing your risk of stroke.

Some of these changes particularly apply to people with contributing factors such as high blood pressure and high cholesterol. Eating a healthier diet may only involve making small changes in meals you already eat – eating a little more of some things and less of others.

A healthy varied diet should include foods from all food groups – carbohydrates (such as pasta, rice, potatoes, root vegetables and bread), proteins (such as meat, eggs, fish and poultry), dairy products, fruit and vegetables.

The general healthy-eating message is to:

• eat at least 5 portions of fruit and vegetables each day
• increase the intake of fibre in your diet
• reduce the fat in your diet, replacing saturated fats with unsaturated fats or oils.
• eat less sugar
• moderate your salt intake
• check the food labels – this gets you used to knowing what is in the food you are eating

More about eating a healthy balanced diet

Drug misuse

Some recreational drugs – like cocaine, amphetamines (speed) and ecstasy – can cause your blood pressure to rise. Some recreational drugs can increase your blood pressure, and many illegal drugs and so-called ‘legal highs’ affect the heart.

As well as lots of other effects on your brain and body, they can cause raised blood pressure, increased heart rate and an irregular heartbeat. Cocaine causes your coronary arteries to constrict, raising your blood pressure and reducing the blood supply to your heart. During the first hour after cocaine use, the risk of a heart attack increases by nearly 24 times. The risk of heart disease amongst cocaine users is compounded by other risk factors, including smoking and drinking excess alcohol – the combination of all 3 can be a lethal cocktail.

More about drug misuse

Other risk factors

You may be one of the people who does not have any of these risk factors but still develops heart disease. You may have other genetic factors (that is, passed on through families) that may increase the likelihood of you developing coronary heart disease. Other risk factors are known to affect the chance of developing coronary heart disease. These include age and being male or female.

If a close member of your family has been affected by coronary heart disease, you should do everything possible to reduce your risk of heart disease. It is also important that your doctor carries out a cardiovascular (CVD) risk assessment on you to find out any specific risk factors that you may have.

Ethnicity

Rates of high blood pressure and diabetes are higher in people of African and Afro-Caribbean descent, which means that they also have an increase risk of CHD and heart attacks.

People of South Asian descent (those of Indian, Bangladeshi, Pakistani and Sri Lankan origin) are 5 times more likely to develop diabetes compared to the population at large. Again, this also increases their risks of CHD and heart attacks.

If a heart attack is suspected, you should be admitted to hospital immediately. You will usually be admitted to an intensive care unit (ICU) so that the diagnosis can be confirmed and treatment can begin.

Initial tests

As soon as ambulance or medical staff arrives, they will begin tests to find out what is happening to you. These will include:

• ECG (electrocardiogram) - to show the amount of damage to your heart muscle and where the damage is. Treatment to restore blood flow and minimise the amount of heart muscle damage (this is called ‘reperfusion’) can be achieved in different ways depending on your ECG readings, so it is important that you have an ECG as soon as possible to show exactly what is happening.
• assessment of blood pressure and blood oxygen levels
• blood tests

Establishing a diagnosis

An ECG will show which of the two main types of heart attack you have had with a heart attack being identified by abnormal changes on your ECG reading, (that is, changes to the pattern of a normal heart beat). This is called ST elevation. The presence and degree of ST elevation indicates the severity of blockage in the blood flow to your heart.

Your ECG will show which of the two main types of MI (heart attack) you have had. There are two possible scenarios:

• Your ECG shows a complete blockage - this is known as ST Elevation Myocardial Infarction (STEMI).
• Your ECG shows a partial blockage, but some blood is still able to flow (this may lead to a full blockage). This is known as Non ST Elevation Myocardial Infarction (NSTEMI).

Which type of MI you have had will decide what emergency treatment is right for you.

Sometimes, when chest pain occurs suddenly, it is unclear if it is due to unstable angina or a heart attack, and then another type of treatment would be required.

Until tests confirm your diagnosis, doctors may describe your condition as Acute Coronary Syndrome (ACS). Prompt tests, investigations and diagnosis are important so that the appropriate treatment can be given to you as quickly as possible.

Blood tests

Routine blood tests include:

• Full blood count (FBC) - this test measures the levels of red blood cells, white blood cells and platelets. It also measures the haemoglobin (oxygen carrying component of red blood cells).
• Urea and Electrolytes (Us & Es) - urea levels help to monitor how the kidneys are working. Electrolytes (eg sodium, potassium) and minerals (eg calcium) help to stabilise the heart rhythm.
• Glucose - this test measures the level of sugar in the blood.
• Liver and thyroid function - this test can show any other abnormalities.

Other blood tests

These include:

• troponin blood test - troponin is a protein which is released into the blood stream when the heart muscle is damaged. The troponin level provides a quick and accurate measure of any heart muscle damage. It is used to help diagnose a heart attack and may need to be taken on admission to hospital and/or 12 hours from the onset of symptoms.
• checking for altered hormone levels - this can be a possible cause of high blood pressure
• cholesterol level and lipid profile

Chest X-ray

A chest X-ray can be useful if the diagnosis of a heart attack is uncertain and there are other possible causes of your symptoms, such as a pocket of air trapped between the layers of your lungs (pneumothorax).

A chest X-ray can also be used to check whether any complications have arisen from the heart attack, such as a build-up of fluid inside your lungs (pulmonary oedema).

Echocardiogram

Sometimes referred to as an ‘echo’, this is an ultrasound heart scan. First, a special jelly is applied to your chest. An operator then lays a probe on the chest and moves it around, on the jelly, to get different views.

Sound waves bounce information about the structure of the heart back to a computer to make a picture of the heart. This tells the doctor about:

• the size of your heart
• how well your heart muscle is working
• how well your heart valves are working

Coronary angiography

An angiogram is an X-ray examination of your heart (also called cardiac catheterisation), which is used to assess damage to your coronary arteries.

A catheter (tube) is inserted, under local anaesthetic, into a main artery in your upper leg or lower arm and then passed gently into your aorta (the large artery which supplies the heart muscle with its own blood supply). A dye is then injected which fills the blood vessels of your heart (coronary arteries) and an X-ray picture is taken. This picture can then be studied to assess which arteries are blocked and how severe the blockages are.

You cannot feel the catheter in your heart, but some people experience a ‘hot flush’ when the dye is injected. Interventions to treat a blockage can sometimes be performed at the same time as an angiogram. This is called percutaneous coronary intervention (PCI) or angioplasty.

Your treatment plan will depend on the type of heart attack you have had.

There are two immediate aims to the initial treatment for a heart attack:

• to relieve pain and shock 
• to restore blood flow and minimise the amount of heart muscle damage (this is called ‘reperfusion’).

What treatment you receive will depend on the type of heart attack you have had.

Emergency treatment

Early reperfusion minimises the extent of heart muscle damage and preserves the pumping function of your heart.

Fast medical attention and evaluation of your individual situation by ambulance and/or medical staff, and your geographical access to treatment centres, will determine the course of action best for you.

Treatment for pain and shock

This can include injections of strong pain-relieving drugs such as morphine. This also helps to relax your breathing and ease anxiety. There is also oxygen therapy (to help with your breathing and help your body to get enough oxygen) and drugs to stop sickness and nausea (anti-emetics).

Antiplatelet therapy

Antiplatelet therapy is a form of drug that thins the blood and prevents clotting. This starts the process of getting rid of the clot that is blocking a coronary artery as quickly as possible. This is given regardless of what type of heart attack you have had that is, in both STEMI and NSTEMI.

It consists of:

• an initial dose of 300mg aspirin, either in the ambulance or as soon as you get to hospital
• further antiplatelet therapy, depending on the results of your initial tests

Reperfusion treatment

Emergency treatment to restore blood flow (reperfusion) minimises the extent of heart muscle damage and preserves the pumping action of your heart. Reperfusion can be achieved in different ways depending on what type of heart attack you have had. Percutaneous Coronary Intervention (PCI), also called angioplasty, treats blockages within your coronary arteries and restores blood flow to your heart.

Percutaneous Coronary Intervention (PCI)

Primary PCI is a procedure which treats blockages within your coronary arteries and restores blood flow to your heart. During an angiogram, a thin catheter is inserted, under local anaesthetic, into a main artery in your upper leg or lower arm and then passed gently into your coronary arteries (the arteries which supply your heart muscle with its own blood supply). The clot or blockage is located and removed.

Thrombolysis involves an infusion of a ‘clot-busting drug’, which is given directly into your vein. This drug (usually tissue plasminogen activator (tPA) or alteplase) dissolves the clot(s) within your coronary artery and restores blood flow to your heart. Treatment with thrombolysis is most effective when it is given as soon as possible. For this reason, it may be given by paramedics in some areas or shortly after arrival in hospital. This treatment is not suitable for everyone, as there is a risk of bleeding.

Both treatments will have the best results when given as soon as possible.

Aims of treatment

Broadly speaking, the main aims of treatment for heart conditions are to:

• prevent worsening of heart disease
• prevent complications of heart disease
• ease the strain on your heart
• control any symptoms you have
• help you maintain as high a level of activity as possible
• improve your quality of life

Treatment can be divided into:

• medical treatment with drugs
• surgical interventions

Drugs

Some people with heart conditions have to take several different drugs every day. Though this can sometimes be difficult to deal with, try to remember that your doctor is aiming to keep you as well as possible and will try to find the best drugs for you with the fewest side effects.

Remember to:

• always take your drugs as prescribed by your doctor
• report any side effects but do not stop taking any drugs suddenly or without your doctor’s advice
• discuss all over-the-counter remedies with your pharmacist to make sure they won’t interact with any prescribed drugs you're taking

Complications following a heart attack

Sometimes there are complications following a heart attack. The most common complications after a heart attack are:

• problems with your heart’s natural electrical rhythm
• chest pain or angina
• heart failure

Many problems resolve themselves quite quickly. However, sometimes problems linger and can often be helped by the use of drugs.

Arrhythmias

Your heart’s natural electrical rhythm may be affected by your heart attack. When this occurs, you can subsequently develop an arrhythmia. Sometimes it is necessary to insert a temporary pacemaker for a few days until this settles down.

A pacemaker is a special electrode that is inserted to allow your heart to beat regularly when its own natural pacemaker has been affected. The electrode is attached to a small box that has to be carried around with you. Occasionally, this has to become permanent, and a tiny pacemaker is inserted under the skin.

If your heart develops a rhythm that could be life-threatening, an Implantable Cardioverter Defibrillator (ICD) may be suggested. This is similar to a pacemaker but delivers different treatments.

Chest pain or angina

Sometimes damage to blood vessels can lead to angina. Angina is chest pain that is caused by insufficient blood supply to your heart muscle. Angina can occur before or after a heart attack, as one or more of your coronary arteries may be narrowed. Your doctor may suggest a test called an angiogram to look at your coronary arteries in more detail.

Heart failure

When there has been damage to a larger area of heart muscle, the pumping action of your heart is affected and cannot meet the body’s demands for blood and oxygen. When this happens, it is referred to as heart failure because of the failure of your heart to work efficiently. Symptoms such as fluid retention, tiredness and breathlessness can result.

How long you stay in hospital for will depend upon your individual circumstances as well as what treatment you receive. You may find that you don’t really remember a lot of what the doctors and nurses told you, especially during the first few days. Don’t be afraid to ask questions of staff and talk to your family about what has been happening.

If you live alone, it is advisable to arrange to stay with friends or family for a few days, as you may still feel a bit shaky and weak. This is partly because you may have been inactive for a while and partly because of the shock.

You will then enter a recovery phase, which is very individual to you and should centre on your own needs and wishes. This phase is often supported with a cardiac rehabilitation programme.

The aim of cardiac rehabilitation is to support you in your recovery by providing you with the information and emotional support you need to develop your own self-management skills, to pace your recovery, and to regain your fitness and confidence. It combines physical recovery with education about lifestyle risk factors, information about any drugs you have been prescribed, and emotional support. It can also be helpful for your family and friends.

Your local trained health professional (often a nurse) will assess you to provide your own individual programme, whatever your level of fitness. The time frame for starting cardiac rehabilitation varies, but you are normally ready to begin a few weeks after your heart attack.

The format cardiac rehabilitation takes does vary across Scotland. Some programmes take place in a hospital or community setting. Alternatively, your cardiac rehabilitation may be provided as a home-based programme you manage yourself with local support from your cardiac rehabilitation nurse or your GP.

Reducing the risk

Reducing your risk of having another heart attack involves making lifestyle changes and taking a long-term course of a combination of different medications.

It is natural to have fears about the future and to worry, especially when you have just left the protective environment of the hospital. Try to concentrate on the positive things (such as having come through the worst) and focus on getting stronger every day.

The heart has great capacity to heal – within a couple of weeks, a scar will form in the damaged area. Often your heart can recover and is able to work just as well as before.

The sooner you can get up and about, the sooner you'll feel better. You must not push yourself too hard. but you must not allow yourself to become afraid of activity.

Try to keep yourself busy with light hobbies such as reading, watching TV, using the PC and listening to the radio. Keep in touch with people by telephone, text or email, and have friends to visit when you feel up to it – the company may help to lift your spirits and stop you dwelling on what has happened.

Changes to your lifestyle

It’s wrong to think that having a heart attack means it's already too late and that the damage is done.

It's much better to think about this as a new start and another chance – a chance to take responsibility for the things you can change, and to work together with doctors and nurses to control the things you can’t.

The best way to prevent another heart attack is to understand what caused the first one and take steps to reduce your risk of having another heart attack.

There are certain things that increase your risk of developing heart disease. These are called risk factors.

Risk factors are not the cause of your heart attack, but they have contributed to your heart attack happening. In other words, by reducing these risk factors, you can reduce your overall risk of heart disease.

Some risk factors are to do with things you cannot alter, like family history, age or ethnic origin. However, many risk factors are to do with the way you lead your life and habits that you have created. With a bit of effort, you can change your lifestyle, and habits can be broken. 

You can involve your family in any lifestyle changes you make. It’s important to identify, honestly, any of the things in your life that you can do something about to improve things:

Returning to work

For most people, there may follow a period of cardiac rehabilitation, following a diagnosis of a heart condition or heart disease, before returning to work. This will depend, mainly, on the type of work you are involved within and the physical and mental activity required. (like manual labour or a desk job). There may be a period of time prior to returning to work that requires some discussion with your employer, yourself, the medical team and occupational health departments to find out what’s best for you.

Sometimes, people are not able to return to the job they were employed in following a diagnosis of a heart condition or disease. If this is the case, you and your family will find it helpful to discuss any benefits and support you are entitled to. This can be traumatic for people to learn that they may no longer be able to work, so ensure you talk about this with your family or loved ones, so they can support your anxieties and worries.

Relationships

Many people worry about relationships following a diagnosis of a heart condition or heart disease. It can change the way they see themselves as a person and their place in the home or within the family. This can become problematic if these feelings continue and they begin to become depressed. 

Relationships with partners can be very important in supporting the person who is living with heart disease. This includes platonic and sexual relationships.

Sexual relationships

Remember, any serious health problem can impact on your sex life. Having a heart condition is no different. For anyone who was previously sexually active, this is an important issue, and it can be very important to talk about with your partner and health professional if you are worried.

Many people worry that sex is not safe following heart disease or heart condition diagnosis. For most people, sex is safe and can be thought of as a form of exercise (in terms of your heart work). It is no more stressful to the heart than other forms of moderate exercise. If you think of sex as a physical activity, then making love raises the heart rate about as much as climbing two flights of stairs. Sex, like any exercise, raises your blood pressure but only briefly. Your blood pressure falls immediately afterwards. This temporary increase in blood pressure is normal and safe. Attending cardiac rehabilitation can give a person confidence in increasing activities, which can lead them to resuming their previous sex life for them and their partner.

If your sexual relationship had deteriorated prior to the heart attack, then being close to your partner and supporting them in a close and supportive way may feel more like your previous relationship and is also very important.

If there are physical problems that are causing you problems achieving your normal sex life, such as erectile dysfunction (impotence), discussing this with your health professional is advised to find out any options for you. It is very important following a heart attack or living with heart disease that no medication is taken without medical consent.

Driving

If you drive a car or motorcycle and you have a heart attack, you do not have to inform the Driver and Vehicle Licensing Agency (DVLA). However, the DVLA strongly recommends that you stop driving for at least four weeks after a heart attack. After this, you will be able to drive provided you do not have any other condition or complication that would disqualify you from driving.

If you drive a large goods vehicle or passenger-carrying vehicle, you must inform the DVLA if you have a heart attack. Your license will be temporarily suspended, for a minimum of six weeks, until you have adequately recovered. Your licence will be reissued if you can pass a basic health and fitness test, and you do not have any other condition or complication that would disqualify you from driving.

Depression

Having a heart attack can be very frightening and traumatic, and afterwards it is common to have feelings of anxiety. For many people, the emotional stresses can cause them to feel depressed and tearful for the first few weeks after returning home from hospital.

If feelings of low mood or depression persist, speak to your GP or health professional about how you are feeling, because you may need additional support. It is important that you seek advice, because serious types of depression often do not get better without treatment. Your emotional state could also have an adverse effect on your physical recovery. 

More about dealing with low mood and depression